Flaccid Paralysis Treatment After Stroke

Questions and Answers

The questions below were submitted to stroke-rehab.com by readers regarding flaccid paralysis treatment. This was a popular Ask The Therapist topic, so a total page has been devoted to it. Flaccid paralysis (or flaccidity) after a stroke refers to a specific type of muscle weakness that occurs as a result of damage to areas of the brain responsible for controlling muscle movement. It can lead to weakness or paralysis of the affected muscles. 

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Flaccid paralysis is characterized by a loss of muscle tone, meaning the affected muscles become limp and unable to contract properly.

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Flaccid Paralysis Treatment?
by Christy

Question: What is the protocol for flaccid paralysis treatment after stroke? How long does this flaccid stage usually remain?

Answer: There is no set amount of time that the flaccid stage remains. For some, it can resolve in days, others weeks or months. Most stroke patients don't remain flaccid and will gain some tone which can range from minimal to severe. There is no specific protocol for flaccid paralysis treatment after stroke, but the following are recommendations.

1) Positioning of Flaccid Arm

Isotoner Therapeutic Gloves, Full Finger

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During the flaccid stage, it is important to keep the arm supported and well-positioned. Elevation, manual edema mobilization, compression garments, and edema gloves can be used to help with hand/forearm edema (unless contraindicated due to CHF or similar diagnosis so always check with MD first).

Slings are an option, but I don't personally like slings because they immobilize the arm and often cause poor positioning and alignment. If I do use a sling, it's usually only when a patient with a flaccid arm is walking so that the arm does not hang heavily by the person's side.

Pillows or trays like the ones below from Amazon can help support the weak arm. One sided trays are preferable so the stroke patient is not constrained to the wheelchair.

Skil-Care EZ on Lateral Support for Wheelchair, Provides Comfort and Stability for Shoulder and Arm

Secure Safety Solutions SDAS-Wheelchair Arm Rest Lateral Support Cushion

Rehabilitation Advantage Wheelchair Arm Tray with Foam Arm Elevator

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Caregivers should never pull on the flaccid arm and should make sure the arm and leg are always positioned well. Often a patient will sit on the arm or have the arm/leg contorted in a bad position without even knowing it. It is important to tell the patient to frequently look at the weak extremities and see where they are positioned.

2) Passive Range of Motion Exercises

As far as exercises are concerned, it is important to do passive range of motion exercises to help increase awareness of the flaccid arm and keep joints from becoming tight. The main precaution is to be careful with overhead range of motion and only move the shoulder in a pain-free range. If the patient is unable to do passive range, the caregiver can do it. Examples of a caregiver doing passive range of motion can be viewed on the video below, however, this demonstration is being done on an individual without stroke. It is important to talk to a PT or OT about range of motion precautions and proper technique because some stroke patients should be limited to 90 degrees of shoulder flexion due to inadequate shoulder blade movement or shoulder subluxation.

3) Weight Bearing

Other exercises that should be performed involve weight bearing, facilitation, and trying to elicit movement through gravity eliminated or assisted planes. Weight bearing is important to help bones from becoming weak and can help with muscle strengthening once patient can support some of the weight. Facilitation and use of gravity reduced planes can help elicit weak movement.

Weight bearing can be done by the caregiver placing the patient's open hand on a flat surface (i.e. mat, bed, book), supporting the patient's elbow so the arm won't buckle, and having the patient lean and put weight down through the flaccid arm and hand. Attempting to stand while a therapist or trained caregiver assists can help with weight bearing through the leg, but sitting balance and trunk control should be established first.

HomelyD Hi-Lo Adjustable Treatment Table As an Amazon Associate I earn from qualifying purchases.

If the patient is unable to stand and weight bear even with the help of a therapist, a hi-lo mat can be used to start weight bearing. I often will have the patient sit on the edge of a high-lo mat that is raised with the patient's feet on the floor. Raising the mat and having the patient reach forward allows for increased weight bearing through the legs, but this is an activity that should be done with the therapist.

4) Facilitation of Muscles

Facilitation can be done by tapping the muscles to try an initiate movement or by using electrical stimulation (if approved by MD and therapist). To help bend the arm, you can tap the biceps. To help straighten the arm, the triceps can be tapped. To help straighten the knee, tap the quadriceps.

5) Electrical Stimulation (if approved by MD)

Balego NMES Muscle Stimulator As an Amazon Associate I earn from qualifying purchases.

Electrical stimulation can be used if approved by the MD and the patient has no contraindications for use (e.g. pacemaker, defibrillator, skin issues, etc.) A therapist can teach the patient how to use electrical stimulation and help the patient find a home unit if advisable. Always check with your physician and therapist first.

6) Active Assisted Range of Motion (AAROM)

Sometimes the extremities appear flaccid but actually do have a little tone and ability to move. Everyday household items can be used to help make elicit and make movement easier. For the arm, a hand towel can be placed on a table and the stroke patient can try to slide it forward. I often use a single tip cane, support the patient's hand on the cane and let them try to push it forward and back (the end of the cane is on the floor while I'm supporting the patient’s hand on the handle).

Sometimes I will place the patient's hand on a table, ball or mat and see if they can hold it there without it falling or sliding off. These are a couple of beginning exercises that can be tried to see if there is any active arm movement.

Edema of Fingers in Flaccid Arm

Question: Will Isotoner help to reduce dependent edema in flaccid fingers of a flaccid arm?

Answer: There are Isotoner therapeutic gloves that can help with swelling. Wearing of the glove can be combined with elevating the hand above the heart, and manual edema mobilization by a therapist if necessary. If movement begins to return to the flaccid hand, it is important to start trying to open and close the hand and use the hand to help decrease edema.

There are some medical conditions that aren't appropriate or require close monitoring when dealing with edema management so it's important to check with your physician prior to initiating the use of edema control garments or techniques. Some examples of these medical conditions may include congestive heart failure (or other cardiac conditions with potential for volume overload), severe peripheral vascular disease, blood clots, infection, kidney disorders, and skin disorders.

Flaccid Stage Duration

Question: I have a patient with left side hemiplegia. 12 days after the CVA, he still persist in the flaccid stage. This stage may remain for how much longer?

Answer: Unfortunately, I cannot answer your question. Some people stay in the flaccid stage for only a few days and others have flaccidity for months. At some point, most stroke patients will begin to develop tone in their arm. Sometimes functional movement will be regained and sometimes tone and spasticity can set in without the presence of functional movement. Only time will tell.

Range of Motion (ROM) Limits

Question: Why should range of motion over 90 degrees of shoulder flexion be avoided on a flaccid extremity?

Answer: It doesn't have to be totally avoided, but it must be done correctly and without pain. When passively raising the flaccid arm above 90 degrees the shoulder blade or scapula has to rotate upward to allow for movement of the humerus (upper arm bone). If the scapula does not rotate, then structures can be impinged, damage can occur, and pt. may also experience pain. Some patients may not be aware of the pain because they have lost sensation, so you cannot rely on patient report. The humerus also needs to be externally rotated rather than internally rotated. A therapist can instruct a caregiver on how to help the scapula and humerus rotate and perform ROM in a correct manner.

Flaccid problems
by Bala (Coimbatore, Tamilnadu, India)

Question: Hello, my patient was attacked by a pontine stroke 4 months ago. He is able to do only elbow flexion and mild finger flexion but his arm remains flaccid. He can walk with help but his arm remains the same. Give any tips. He is currently getting electrical stimulation, mild stretch, and passive ROM up to pain free movement.

Answer: A pontine stroke is a stroke affecting part of the brainstem and can result in extensive loss of motor function. You cannot control how much motor return a person can get, but rather you are strengthening what return they do have and also helping the stroke victim identify any muscle movement/contraction that they may not be aware of because it is so weak. So the key to seeing if you can get more movement is to assist weak muscles. This can be through gravity eliminated planes, use of e-stim, assistance through outside means (e.g. the unaffected arm, another person, a piece of equipment), and sometimes putting the person in a position that affects tone/reflexes and then allows for more movement.

You are already using e-stim, so here are some examples of flaccid paralysis treatment after stroke:

1) Gravity Eliminated Plane

For the shoulder, an example of this would be lying on the non-affected side and having the person try to reach forward (with the arm either supported by you or you could rest the arm on a smooth surface and put a washcloth under the hand and have them slide it forward). For the leg, the person could lie on their back with a large, smooth surface placed under the foot (plexiglass sheet or transfer board). The foot would then be placed on a small towel (or just have a sock on the foot) while the person tries to slide the leg sideways.

2) Assist by Person or Equipment

 For the shoulder and elbow, I like to place the person's hand on a cane and the cane tip on the floor. You can help the patient hold to the cane or wrap their hand on the cane with an ace bandage if needed. The person then will try to push the cane forward and back. There is a piece of equipment that is more expensive but is specifically meant for this same purpose that is called the UE Ranger. It also has wall attachments so that the patient can work on overhead movements.

Another example of equipment assisting is using an arm support - they have equipment for this such as the Saebo Mas or suspension mobile arm support/sling, but it can be expensive. One such example is a Swedish arm sling. A cheaper setup can be rigged to achieve a similar setup (e.g. using a band from overhead or making your own device) though it may not be quite as effective. You can also help support the weight of the arm by putting it on a table and having the person try to slide a washcloth forward. To assist biceps, you can give a person a lightweight ball between both hands and see if they can bring it up toward the chin (the other hand helps - you can help support affected hand if it tends to fall off or just have them practice holding ball between two hands first).

3) Use Positions That Favor Better Movement

Sometimes the position of a patient will affect the tone in their arm or leg and can be beneficial to eliciting movement. A good example of this is having the patient lie in supine (on their back) and trying to facilitate elbow extension (straightening the arm). If you support the upper arm with the shoulder at 90 degrees (if tolerated), the person can often straighten the elbow bringing the hand up toward the ceiling especially after the therapist does a little facilitation such as tapping the triceps or a quick stretch to the triceps. Once the person feels the movement, they can often begin to do repetitions on their own. To do quick stretch to the triceps, you would bend the person's elbow and do quick little presses against the forearm into elbow flexion.

These are just some examples of treatment ideas. The options are limitless to try with a little imagination, however, remember that you can only enhance what has returned or is returning. Sometimes there is just no return, and in that case, there isn't anything you can do to "make it return".

Therapy on the Weak Side

Question: My husband had a stroke a little over a month ago. It was a left MCA stroke. His right shoulder is subluxated and the arm is flaccid. He has some movement of the right leg i.e. can move it sideways towards the left, and if supported, he can kick the leg out.

In therapy, they work only on his left side with stretching, strengthening, etc. When do they start to work on the right side? It seems to me that he has some potential to regain the use of the right leg and perhaps be able to walk with a walker in the future. But, if it is neglected now, won’t it just atrophy and become useless? He is only 61 years old.

Answer: I would ask the therapist(s) who are working with your husband what is being done to address the right side and why they are focusing more on the left side. Sometimes therapists may appear to be working only on the strong side and actually be addressing the weak side. An example of this would be trying to weight bear on the weak leg, while lifting the strong leg. The purpose of this exercise isn't the moving of the strong leg but to strengthen the weak leg to be able to take the weight and get the stroke patient to put weight on the weak side.

The same is true for the arm. The therapist may have the patient sit on a mat and have the patient lean on the weak arm while reaching with the strong arm. It appears that the therapist is working on moving the strong arm, but in reality, he or she is working on the patient taking weight through the weak arm and on sitting balance while reaching. If these are the scenarios that you are seeing, then the therapists aren't actually neglecting the weak side. However, I would say that in addition to weight bearing, the therapists should be trying to facilitate movement on the weak side.

If none of the above activities appear to be what the therapists are doing, and exercises are strictly being done with the strong side, then you should definitely express your concerns to the therapist(s). Make sure the therapists working with your husband have experience in working with stroke patients. If your husband's weak side is truly being ignored and your concerns are disregarded by the therapist, then you should consider finding a different therapist. If your husband is in inpatient therapy and will be moving eventually to outpatient or home therapy, then it's a good time now to research or look for good therapists in your area who come with recommendations from others.

Leg and Arm Movement

Question: My husband had a stroke on the 6th of March 2011. He still has no movement in his left arm and left leg. What exercises can he do at home to improve this? He is currently having physio twice a week.

Answer: The return of motor function depends on the severity of stroke. There is no way to know for sure if muscle function will return, but the exercises that I use for facilitating movement are:

1) Weight-bearing activities to the arms and legs with the assist of a therapist

2) Electrical Stimulation (only if approved by the patient's physician and there is no contraindications for the patient)

3) Facilitation techniques - e.g. such as using gravity eliminated/assisted planes, quick stretch and tapping of muscles to facilitate movement

You can also try robotic assisted therapy which can be found in some therapy clinics (i.e. Hand Mentor, Foot Mentor, Amadeo, Pablo, etc.)

I'm sure your physiotherapists are doing everything they can to help. Good luck!

Quick Stretch

Question: What is "quick stretch" exactly? Is it what it sounds like .... Quickly stretching a muscle?

Answer: Quick stretch is used in stroke rehabilitation sometimes to facilitate muscle movement. It does involve quickly stretching a muscle. For example, I use it to facilitate the triceps to move the elbow into extension (straightening of the elbow). The quick stretch often elicits a spasticity response in the muscle which can be useful when trying to get the patient who has had a stroke to move. I find it most helpful when patients have flaccid paralysis and are just beginning to show some trace movement. The response itself does not mean the patient has movement, but can be used to help the patient feel the movement and possibly start eliciting movement on their own.

Trace Muscle Grade
by Nellie (Jackson, Mississippi)

Question: The therapist told me I had trace muscle movement in my left arm following a stroke. I am currently doing outpatient therapy now, but what treatments are the best to use for "trace muscle grade"?

Answer: I like to do facilitation techniques to the triceps to elicit elbow extension or straightening. If you lie on your back, you can have your therapist or caregiver support your upper arm (toward the shoulder) and tap the triceps located in the back of the arm. As the person taps your triceps, you attempt to straighten your elbow and hold it straight. Make sure the person is supporting the upper arm toward your shoulder as you will not be able to hold the entire arm up on your own. As you are able to "learn" the movement, you will get better at it and should be able to straighten the elbow on your own without the helper tapping the triceps. You can then progress to sitting and trying to do elbow extension movements such as pushing a cane forward and back. You can have someone help hold your hand on the cane or wrap it to the handle with an ace bandage if you do not have enough grip to hold on. Above are some pictures demonstrating these exercises.

I also recommend using electrical stimulation unless you have contraindications (e.g. pacemaker, defibrillator, skin issues). Check with your therapist and MD to see if electrical stimulation would be right for you. There are companies that rent out home units that you can use daily at home if prescribed by your MD.

The third recommendation I have is just attempting to move the arm any way you are able. If you have trace finger movements, keep working on trying to move the fingers. You can facilitate movement by tapping the muscle belly that causes the desired movement (e.g. tap on the back of the forearm to open the fingers and on the other side of the forearm to facilitate making a fist).

Hemiplegia and Flaccidity Problem
by Ammulya (Hyderabad)

Question: Hello, I am seeing a patient that experienced a left capsuloganglionic bleed. She was admitted in the hospital for 2 months. She had right shoulder subluxation and flaccidity of the arm. After 2 months, she is still having flaccidity. I am doing flaccid paralysis treatment as per protocol like passive moments, joint approximation, and tapping. Can you please suggest to me what to do other than this to improve her muscle tone?

Answer: Although 2 months may seem like a long time, I have seen patients who continued through the flaccidity stage for months before any tone was seen in the arm. I would absolutely continue what you are doing, provide weight bearing through the arm, and I also would try mental imagery and mirror therapy. If the patient doesn't have contraindications, you could try adding electrical stimulation (e-stim).

Left Eye and Mouth Not Functioning
by John (Musina Limpopo, South Africa)

Question: I am 26yrs old suffering from the left side of my face not functioning. Please help me - I don’t know what to do.

Answer: Have you seen a physician? If it's only your face that is affected, it may be another condition such as Bell's Palsy or Ramsey Hunt Syndrome that affect the facial muscles. Stroke can also affect these same muscles. Either way, if you haven't seen a physician, please see one right away to determine what is wrong. A stroke may start out with certain symptoms and then become worse and even fatal without treatment.

For retraining facial muscles, you could use the same exercises that are used after Bell's Palsy. You can find some of these facial exercises at https://mobilephysiotherapyclinic.in/exercises-for-bells-palsy/. You can also consult a physical, occupational or speech therapist who specializes in facial neuromuscular retraining to help you with exercises or use of biofeedback/electrical stimulation if appropriate. If you do seek out a therapist, make sure he or she has experience in facial retraining as this is a specialized area.

About the Causes of Flaccidity in CVA
by Shamim Mahmooda (Jhelum ,Pakistan)

Question: As CVA is upper motor neuron lesion then why does flaccidity appear first before spasticity?

Answer: It would be best to ask this question to a neurologist or researcher in neurology. My understanding is that the initial damaged area is not functioning so there is a lack of motor control or influence from this damaged area. After a few hours to weeks, neighboring parts of the brain that are undamaged can alter their function to help compensate for the damaged areas to some extent. This is why flaccidity would be seen at first and possible spasticity later. Again, I am not a neurologist, and this is my basic understanding. Researchers are still investigating the effects of stroke on the brain as well to better understand these changes.

Splinting the Flaccid hand in the Acute Phase

Question: What is your opinion regarding splinting the flaccid hand in the acute phase post-stroke. Is it advisable to prevent spasticity of the intrinsics or would it be better to wait until the subacute stage to splint?

Any thoughts on this would be appreciated.

Answer: Interestingly enough, research has not supported splinting in stroke patients for preventing contractures or decreasing spasticity (research has been done for up to 7 months of wear time). This is rather odd since splinting has shown to increase mobility and decrease contracture in orthopedic patients, but obviously the causes of orthopedic and neurological conditions are different.

The only times I personally recommend splints to stroke patients are to prevent skin breakdown or if a splint can provide increased function to the hand (e.g. allows positioning of the hand so that the patient can grasp better or assists patient in release, etc.) Obviously, this would not be the case for a patient that has a completely flaccid hand because tone or movement would not be present yet. If a patient comes to me and already has a night splint that they wear, and they feel it helps, I tell them to go ahead and wear it if they want (after I inspect it to make sure it won't cause any damage to the hand). I always encourage my patients not to wear any such splints in the day though as I want them working on trying to regain movement. I would emphasize though that the flaccid arm should be monitored for safe positioning throughout the day to prevent injury.

I personally think each case is different and that you should keep up with research but also listen to your patients. Here is a recent article regarding static splinting of the upper extremity after stroke: https://www.evidentlycochrane.net/static-splinting-stroke-therapists-overlooking-evidence/. Interestingly enough, you will see some patients' comments that disagree.

Electrical Muscle Stimulation
by Angie (Hendersonville, NC)

Question: Mom 72, suffered a severe stroke on the right side leaving the left paralyzed. While at the first facility she received electrical stimulation (ES). After 4 weeks she had to change to a new facility because of Medicare. The new place does not want to use ES because there is controversy saying it should not be used too soon. It has been two months since the initial stroke. What are your thoughts on this?

Answer: I would ask them to show you research that backs up their claims. When looking at what treatments are effective for stroke, I refer to www.ebrsr.com. EBRSR stands for Evidenced Based Review of Stroke Research. According to the most recent EBRSR data published in 2018, there is mixed evidence regarding functional electrical stimulation treatment. Some studies have positive results and others show no improvement with it. I do not know of a study that indicates it shouldn’t be used early after a stroke, but there are many research studies on e-stim, so I would ask the therapist to supply you with the study or article indicating controversy with early use of e-stim. You can read more about the effectiveness or lack of effectiveness of upper extremity (and lower extremity) treatments at www.ebrsr.com. I personally have used FES if approved by the MD in patients that are two months post stroke.

Hemiparesis Exercise Program
by Herbert Vaughan, M.D. (Stamford, CT USA)

Question: I have a left hemiparesis from an embolic stroke in 1998. My arm is completely paralyzed but I can walk with a quad cane or hemi walker. My question regards an exercise program to strengthen my left leg. Is there a website with a good hemiparesis exercise program that I can try? I'll look around for one on the web, which I'm sure will be found there.

Answer: Here are a few websites with exercises:

https://www.stroke-rehab.com/Leg-Exercises.html

https://www.stroke.org/-/media/Stroke-Files/life-after-stroke/ASA_HOPE_Stroke_Recovery_Guide_122020.pdf

https://www.cdha.nshealth.ca/system/files/sites/122/documents/fame-group-exercise-program-people-living-stroke.pdf

Left arm/hand Flaccid Following Ischemic Pontine Stroke
by Jennifer (Seattle Wa)

Question: Immediately following my stroke, I had weakness in my left hand. As treatment progressed (which ignored the arm and hand) weakness increased until now, one day following release, I have little use of the arm and none in the hand. Just a slight shoulder shrug ability. I am told I can forget ever retaining use of the arm or hand.

I am thinking that an artificial arm/hand is the only option.

Answer: So there have been instances of recovery in pontine stroke even in those who have had bilateral pontine stroke. Here is an article about recovery from bilateral pontine stroke which is usually very devastating and can cause locked in syndrome:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2921010/

I would look for an outpatient therapy program preferably (or home health therapy if you are homebound) and continue to work on the arm for at least 6 months (even up to a year) before assuming there will be little to no recovery and especially since you had little therapy with the arm. Make sure to find a therapist experienced in working with stroke and particularly with flaccid paralysis treatment. Unfortunately some therapists may ignore the flaccid arm altogether if they see no movement, but there are still exercises that can be done.

Affected Hand Still Not Functioning After 1.5 Years Post-stroke

Question: My mother had a massive stroke last may 2019 on the left side of her brain which made her hemiplegic on the right side. She had her skull opened up during surgery.

After a month, she went to rehab but then the rehab center that we went was not good AT ALL as they wanted us to do it for her instead of them teaching her what to do and they had to ask us to leave as my mother was making noises such as shouting and etc after 2 weeks. So we had to go to the private Physiotherapy in December 2019.

On February 2020, thats when she started to walk but then she was not independent to be by herself. In July 2020, we hired a OT and Speech therapy to help her out. However, what saddens me is that both her OT and PT are saying her affected hand cannot function anymore so they stopped working on that hand. I just need a third opinion whether this is true. Please help me as this is very important.

Answer: There are two types of recovery. There is neurological recovery and functional recovery. Neurological recovery comes from brain healing and is a natural, spontaneous recovery that occurs within the first 6 months and is not affected by therapy/rehabilitation services. For those with a corticospinal (motor) tract function that is mostly intact, spontaneous recovery of motor (muscle) impairment has been found to resolve by a fixed proportion. For example, motor recovery of the upper extremity has been shown to improve by a fixed proportion with 70% achieving maximum improvement in first 6 month regardless of initial impairment or rehab services. This proportion has shown to be true for patients from all over the world (Byblow et al. 2015). If there is irreversible structural damage to the corticospinal tract, this will severely limit recovery of the upper limb movement.

Recovery associated with rehabilitation comes from extrinsic factors (not body healing) and is driven more by adaptive or compensatory learning strategies. This type of functional recovery can help brain reorganization. For example, a therapist may help the patient learn to use muscle groups that are working to compensate for those that aren't or a therapist may use equipment to stop excessive movements/tone so that a task can be performed. An example of this would be using a finger splint to help hold the finger straighter for pinching or a hand splint to help assist the finger in straightening for release of an object. A therapist might also help a patient identify movements they didn't know had returned and help them to strengthen those muscles/movements. As the brain repeats these new movements or compensations, the brain adapts/reorganizes to become more proficient at them.

Gains in muscle movement from neurological recovery usually occur in the first year after stroke, but functional gains may continue. If she has absolutely no movement or only trace movement 1.5 years after her stroke, then that is a sign that there has not been good neurological and spontaneous recovery of muscle movement. Therapy cannot "make movement return" if it is not there.

However, if there is some signs of movement or simply uncoordinated movement, then there may be a continued benefit from therapy, and she may be able to continue with functional recovery. I would talk to her MD and ask for a second therapy referral/opinion if you feel she could benefit.

Difference Between Flaccidity and Hypotonia
by Fatma (Kuwait)

Question: My question is if there is a difference between flaccidity and hypotonia? In my point of view, there is a difference in which flaccidity is low motor tone involvement with no voluntary control while hypotonia is low muscle tone with motor control such as Down’s Syndrome where they have low tone with voluntary motor control. I asked you because I tried to find evidence based practice to prove my words, but I did not find any evidence. I need an answer, please.

Answer: At the time of this question, I could not find definitions of flaccidity and hypotonia that deal with voluntary versus involuntary movement in the search that I did. Most definitions I have seen would indicate both as low muscle tone (though I think most would agree that flaccidity is a more severe lack of muscle tone). Professionals and instructors often use the terms hypotonic and flaccid interchangeably when discussing low tone associated with stroke. What might be more relevant to what you are looking for is congenital hypotonia versus acquired hypotonia. Congenital hypotonia would be the type you see with a baby with Down's Syndrome whereas acquired hypotonia would be seen because of something such as an infection, injury, or illness such as stroke.

Regaining use of Paralyzed Arm
by Susan Miller (Aurora IL)

Question: What exercises can a person do to help the reconnection from the brain to the effected body part?

Answer: If there is little to no movement, then I would try graded motor imagery which involves left/right discrimination, imagining moving/feeling, and mirror therapy. You can find out more at www.gradedmotorimagery.com. If movement is present, then I might try constraint induced movement therapy and using the affected arm as much as possible for any movements/activities that could be achieved. You can learn more about CIMT at https://www.uab.edu/citherapy/.

Hemiparesis
by Sonia Chavez (Santa Barbara, CA, USA)

Question: My stepfather had a stroke March 12,2014. He didn't receive help for 5hrs. He was in a medically induced coma for 10 days and lost his speech and mobility. Since then he is able to talk although it is a struggle at times. He is slowly making progress with his ability to walk around the with assistance of a walking stick but gets tired so reverts back to his wheelchair. My question is, he has a brace on his lower right ankle. His right knee is always locked so it doesn't bend when he walks and his leg remains stiff. Is there any possibility for it to regain range of motion or bend again? What is the reason for the lack of bending ability? His right arm also doesn't really move. He usually rests it on the arm rest on his wheelchair. He recently began to move his elbow so we are hoping for mobility to return to his arm with more therapy.

Answer: I cannot say with certainty why his knee won't bend, but it may be due to hypertonicity or contracture (or both). Some individuals can get increased extensor tone in the leg causing the muscles that extend the leg to become very tight causing the leg to stay straight. If an individual then goes without bending the leg for a long period of time, the joint can then become contracted and won't bend. If someone else can bend his knee, then it is not contracted. I would consult with his neurologist to see why the knee is not bending, and if there is anything that can be done especially if excessive tone is the problem.

My Husband Had a Stroke Three Weeks Ago
by Angie (Augusta, GA)

Question: My husband had a stroke three weeks ago and his left arm has feeling but he is not able to move his arm too well. He said that it is too heavy. What can I do to help him?

Answer: You could try active assistive range of motion exercises where you help to assist him moving the arm. You wouldn't completely lift the arm but rather take some of the weight, and then let him try to move the arm in various directions. He can also do self passive range of motion and active assistive exercises where he uses the unaffected arm to help move the weak arm. You can learn more about these exercises by clicking the tabs on my website that are directed toward stroke rehab exercises and passive range of motion. You should also consult with his occupational therapist or physical therapist and have them show you how to help your husband with his exercises. Some rehab centers have devices such as a Swedish sling that will take the weight of the arm allowing the patient to move/exercise the arm if they are able. He can also help support the weight of the arm by resting it on a table and trying to slide a towel on the table in different directions. If he is too weak to move the arm even when the weight of the arm is supported, then talk to his therapist about other options such as electrical stimulation or machines they may have to assist with movement.

Affected Hand Still Not Functioning After 1.5 Years Post-stroke

Question: My mother had a massive stroke last may 2019 on the left side of her brain which made her hemiplegic on the right side. She had her skull opened up during surgery.

After a month, she went to rehab but then the rehab center that we went was not good AT ALL as they wanted us to do it for her instead of them teaching her what to do and they had to ask us to leave as my mother was making noises such as shouting and etc after 2 weeks. So we had to go to the private Physiotherapy in December 2019.

On February 2020, thats when she started to walk but then she was not independent to be by herself. In July 2020, we hired a OT and Speech therapy to help her out. However, what saddens me is that both her OT and PT are saying her affected hand cannot function anymore so they stopped working on that hand. I just need a third opinion whether this is true. Please help me as this is very important.

Answer: There are two types of recovery. There is neurological recovery and functional recovery. Neurological recovery comes from brain healing and is a natural, spontaneous recovery that occurs within the first 6 months and is not affected by therapy/rehabilitation services. For those with a corticospinal (motor) tract function that is mostly intact, spontaneous recovery of motor (muscle) impairment has been found to resolve by a fixed proportion. For example, motor recovery of the upper extremity has been shown to improve by a fixed proportion with 70% achieving maximum improvement in first 6 month regardless of initial impairment or rehab services. This proportion has shown to be true for patients from all over the world (Byblow et al. 2015). If there is irreversible structural damage to the corticospinal tract, this will severely limit recovery of the upper limb movement.

Recovery associated with rehabilitation comes from extrinsic factors (not body healing) and is driven more by adaptive or compensatory learning strategies. This type of functional recovery can help brain reorganization. For example, a therapist may help the patient learn to use muscle groups that are working to compensate for those that aren't or a therapist may use equipment to stop excessive movements/tone so that a task can be performed. An example of this would be using a finger splint to help hold the finger straighter for pinching or a hand splint to help assist the finger in straightening for release of an object. A therapist might also help a patient identify movements they didn't know had returned and help them to strengthen those muscles/movements. As the brain repeats these new movements or compensations, the brain adapts/reorganizes to become more proficient at them.

Gains in muscle movement from neurological recovery usually occur in the first year after stroke, but functional gains may continue. If she has absolutely no movement or only trace movement 1.5 years after her stroke, then that is a sign that there has not been good neurological and spontaneous recovery of muscle movement. Therapy cannot "make movement return" if it is not there.

However, if there is some signs of movement or simply uncoordinated movement, then there may be a continued benefit from therapy, and she may be able to continue with functional recovery. I would talk to her MD and ask for a second therapy referral/opinion if you feel she could benefit.

Comments from Readers

Codman’s Pendulum Exercises for Flaccid Paralysis Treatment?
by: Anonymous

Would pendulum exercise be contraindicated on a flaccid UE? Have client who sustained a shoulder fracture when he fell resulting from a R CVA. Has very low tone but also restricted due to recent break. MD wants pendulum exercise, but our staff fears the exercise may cause increased risk of subluxation of shoulder. Any input greatly appreciated.

Answer from stroke-rehab.com: Normally you would support a flaccid/hemiplegic arm due to weak musculature around the shoulder. I would discuss the unique circumstances of the arm being flaccid from stroke with the orthopedic MD as maybe the MD isn't aware of exactly what is going on and may just being following their normal protocol. If on the other hand, there is return of muscle tone to the arm and no subluxation, then it may not be an issue. I would evaluate the shoulder/arm and amount of tone then discuss any concerns you had with the MD.

Speechless after Stroke
by: Spish

My father is 84 yrs old. Last month he had a stroke and his right Side is paralyzed. In the hospital they said there was nothing they could do. He doesn't talk, move or eat himself. He's always crying when he sees his siblings. Our prayer is to regain his speech. Is there any chances at his age? Now his appetite is very low and we don't know what can we do as family. Thanks.

Response from stroke-rehab.com: You would need to talk to his doctor regarding his prognosis. If you are not satisfied with what they are telling you or the care provided, you could ask for a second opinion and also look into having him transferred to a different facility that works with him more. Sometimes people don't improve, but I have no way of telling you if that is the case for your father or not. The best indicator you can get is probably from your father's neurologist.

Flaccid Paralysis 
by: Anonymous

Since stroke is an upper motor neuron lesion, why is it that some stroke patient still present with flaccid paralysis instead of spastic paralysis?

Answer from stroke-rehab.com: According to Dartmouth.edu, damage to the precentral gyrus or isolated damage to the medullary pyramid produces can produce a rather pure corticospinal tract lesion. This results in severe weakness of distal muscles with little appearance of other findings, such as spasticity and hyperreflexia that are hallmarks of most UMN lesions. Also, initial flaccidity may occur with strokes that later turns into spasticity as the brain experiences neuroplastic changes after the stroke.

Excellent summary of flaccidity
by: Anonymous

My left side was flaccid for several weeks after a hemorrhagic stroke. I cannot emphasize the importance of supporting flaccid upper extremities enough. I had some fabulous nurses who tenderly positioned my arm on a pillow, but I was not alert enough to thank them at the time. I was mad at that useless thing.

Unfortunately, my arm hung heavily too much. I couldn't understand how I could have burning pain down the side of my neck and across the top of my shoulder from the drag of my arm but not feel a loving touch or deep massage. My brother was rubbing my shoulder from behind. I thanked him, saying how good it felt and asked him if he could rub my left shoulder as well as the right. There was a stunned silence -- he'd been vigorously rubbing both shoulders.

Gradually, I became able to move on the left but I still had NO sensation or propioception. I "lost" my hand or foot regularly. To find my hand, I had to feel down, starting at the shoulder. My foot was easier -- I could use vision to find it but I needed reminders to look for it. It was often tucked away, where putting weight on it might cause a sprain or a fall.

When I started having some feeling, I realized I was trashing my elbow, hitting the bed rail or arm of the wheelchair many times each day. I didn't know where my arm was, so it kept banging things.

Last month, I told my therapists that my next goal is to be able to pass a field sobriety test stone sober. Don't know if I can ever do that, but I'm working on it. Hopefully, I'll be able to drive, but I hope never to need to pass a field sobriety test. People have said that they wouldn't notice my issues if they weren't looking for them.

I am getting better with the help of skilled and experienced therapists, but I'm like a puppy -- I know when I've done wrong. It doesn't always stop me from doing things that could cause me to fall or hurt myself. I'm still getting stronger and more coordinated. I've typed all this with two hands. That is remarkable!

Study
by: Anonymous

Can you site studies that show weight bearing in a flaccid arm promotes neuro ed?
Thanks for your help

Answer: The research studies below show how weight bearing improved functional outcomes. Weight bearing is important for many reasons including preventing loss of bone density, providing sensory input to joints/skin, producing co-contraction of muscles around a joint (especially hip/shoulder) that is needed for functional activities, and for strengthening to support body weight. In fact, there are many more studies in the orthopedic realm that talk about the importance of closed chain exercises. This can be carried over to neuro patients especially those that do not have the strength to move a limb yet against gravity but that can do some easier weight bearing exercises that activate muscles for strengthening. In fact, weight bearing with the arm on something like a ball provides sensory input and allows the patient with very little to no movement the opportunity to start co-contracting muscles and produce active assisted movements.

https://www.researchgate.net/publication/263399298_The_Effects_of_Weight-Bearing_Exercise_on_Upper_Extremity_Activities_Performance_in_the_Female_Stroke_Patients

https://www.jospt.org/doi/abs/10.2519/jospt.2003.33.3.109

https://www.jptrs.org/journal/view.html?uid=50&&vmd=Full

https://lermagazine.com/article/inserts-improve-symmetry-velocity-in-stroke-patients

Flaccid Paralysis Treatment
by: Anonymous

I'm a IV year Occupational therapy student and these answers you are giving are so simple, but they make Soooo much more sense than my notes!!

Weight Bearing Exercises
by: Anonymous

What are the physiological effects of the weight bearing exercises on the muscles and joints?

Answer from stroke-rehab.com: Weight bearing helps maintain bone density. It applies tension to muscle and bone, and the body responds to this stress by increasing bone density. Weight-bearing exercise can also help reduce the risk of fractures by improving muscle strength and balance, thus helping to prevent falls.

Flaccid Arm
by: Anonymous

Question: Can you muscle test a flaccid arm?

Answer: Manual muscle testing is considered to be inaccurate with stroke patients that have tone disorders due to the problem originating with the brain rather than the muscles. You can test someone with flaccidity, but obviously if someone has a truly flaccid arm with no noticeable contraction, their MMT score would be 0.

When I have a patient with a flaccid arm, I do check for movement at all joints in the arm as there can be flaccidity in one part of the arm and not in the other.

Excellent
by: DR. SAAD

I like your way of teaching the flaccid paralysis treatment criteria for a flaccid arm

Some Flaccid Paralysis Treatment Ideas
by: Anonymous

This is some of the treatment in flaccid Stage :
1- positioning (very important)
2- weight bearing on joints (very important)
3- Having patient to gait (with support of effected side & knee/knees if needed)
4- Movements in middle line
5- Rotational movements (trunk)

If you have other questions regarding flaccid paralysis treatment after stroke, you can Ask the Therapist.

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